For thousands of years we have guided the evolution of dogs to fulfill our needs for work and companionship. Service dogs are pretty remarkable. I love to watch herd dogs mimicking the dance of predator and prey. When you see a guide dog help someone navigate a building or street, you can’t help but to be impressed by the dogs “devotion” and “skill”.

It seems there is a new canine skill in the news every day. Now, in addition to the traditional roles guiding the blind and deaf, and helping the physically disabled, dogs are claimed to be able to calm autistic children, detect blood pressure changes and seizures, and find cancers. Dogs have been used in the bed bug epidemic to find the critters (with little scientific evidence of success).

Humans and dogs have co-evolved successfully to create strong owner-dog attachments (to the point of pit bull owners defending their dogs rather than acknowledging a dog’s danger to humans). It seems intuitive, and is quite plausible, that dogs can calm us, can help lead us in ways analogous to their roles in nature (if “natural” can even be applied to dogs). It’s easy to see how herding behavior can be adapted into guide dog behavior, or hunting behavior into chemical detection.

What’s less clear is whether any of these roles are based on fact rather than intuition.(more…)

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Quacks lie. In some ways, that’s what separates us from them. Real doctors are stuck with the messy truth: with bad news, with uncertain outcomes. It’s this reliance on the truth which gives us much of our credibility.

Laws forcing doctors to lie to patients take me back to reading Kundera in the 80s; the hovering fear that everyday actions might bring the authorities to your door. These feelings affect every portion of your life, whether you are a patient or a doctor. Lying in service of the state is pervasively oppressive. Laws requiring doctors to lie have become a popular tactic in the abortion wars.

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A few days ago, I had the good fortune to share lunch and ideas with David Gorski and Kimball Atwood. Kimball was on his way from a talk at Michigan State to one at Brigham and Women’s, one of the country’s best-known teaching hospitals. David was planning a future talk for a group in Florida. These guys have been thinking and writing about alternative medicine for a lot longer than I, and it was great to pick their brains, toss around ideas, and just hang out on a nice fall day.

We were discussing many of the inanities of so-called alternative medicine touted for use in “real” diseases, that is, not just symptomatic care. There have been, for example, an number of studies out of China in the last few years claiming that acupuncture helps with in-vitro fertilization. All of these studies have been terribly flawed, and the reasons for these flaws are interesting, but irrelevant beside the primary flaw: the ideas are so implausible as to render any conclusions invalid. It is very difficult to understand how acupuncture in any of its forms could improve chances of conception, either in vivo or in vitro.

During our visit, Kimball brought up a rather interesting analogy: if acupuncture could increase fertility, shouldn’t it also be able to decrease it? We have scads of alternative treatments for the common cold, back pain, headache, multiple sclerosis, diabetes—everything, really. Why not contraception? After all, no one likes condoms, and the pill comes with its own baggage. Nuva rings and IUDs are convenient, but can be annoying to use, or can cause problems in certain patients. And almost all contraception relies solely on the woman. The only possible contribution a man can make is condom use or vasectomy.

Where is the alternative medicine community? They are usually pretty keen on getting involved in common medical problems. Undesired pregnancy is a common problem. Where are the studies on acupuncture for contraception? Homeopathy? Chiropractic?

How would these treatments look? Acupuncture could perhaps stimulate the qi involved with spermatogenesis, causing a feedback inhibition, right? Homeopathy, well, if a lot of sperm heading to the egg are the cause of pregnancy, then a little bit of sperm should do the trick I’d think. You could even put them in a lozenge. And with vertebral subluxations able to cause all manner of medical problems, shouldn’t a good chiropractor be able to shove around a vertebra, impeding sperm production or release? Contraception is big business. Where are these guys?

Let me very clear that I am a traditionalist when it comes to contraception, preferring those methods that have been proven safe and effective. I don’t give medical advice online, but I might make an exception here.

Speaking of implausible, after looking at some of Kimball’s slides, I wanted to do this just for giggles.

Common cuts of beef vs. Reflexology chart

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In 2000, a panel of experts was brought together by the Centers for Disease Control and Prevention (CDC). They came to discuss whether measles was still endemic in the United States, that is whether it still existed in the general background of US infectious diseases. They concluded that measles had been eradicated in the US, and that the occasional cases imported from abroad were stopped by a wall of vaccinated Americans.

Welcome to the future. The US is in the middle of its largest measles outbreak since 1996. Most of the cases originated abroad, brought back by unvaccinated travelers, either American residents or foreign visitors. This has so far led to 12 outbreaks (that is, a cluster of three or more connected cases) mostly among the unvaccinated. Of the 139 cases who were US residents rather than foreign visitors, twelve had documentation of adequate immunization.

The surprise isn’t that a few cases should slip through the wall of vaccination, but that the wall has so many chinks in it. The number of measles cases being imported, and the falling vaccination rates of Americans may reach the point soon where we no longer need to import our measles as it will once again become endemic.

Measles isn’t just a curious disease that we learned about in medical school (“cough, coryza, conjunctivits”); it’s a serious disease that leads to pneumonia in 1 in 20 children, and brain inflammation in 1 in 1000. Outside the US, it causes hundreds of thousands of deaths yearly.

We must increase our efforts to vaccinate all US residents properly (including undocumented residents). If measles does take hold once again in the U.S., the blame will fall squarely on our health care system’s failure to deliver vaccine, and on those who for whatever reason delay or avoid vaccination altogether.

It used to be that Americans viewed public health battles with excitement, a battle against fear itself, against the fear of children choking to death from whooping cough, or becoming paralyzed by polio. Now, as we sit behind our crumbling shield of vaccination, we have become complacent. If we fail to act, our complacency will be replaced by very real fears, especially for our children.

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There is quite a bit of art to the practice of medicine: knowing how to get and to give information to a patient, how to create a sense of worry without creating a feeling of panic, how to use the best available science to help them maintain or return to health. Underlying all of the art is the science: what blood pressure is likely to be harmful in a particular patient? What can I offer to mitigate this harm? This science is developed over years by observation and systematic study. We have a very good idea of what blood pressure levels are optimal to prevent heart attacks in various populations. These data are hard-won. It has taken decades and it continues.

If a researcher were to discover a promising, new blood pressure intervention, they would have a long way to go from bench to bedside. They would have to prove as well as possible that it is safe and effective—and from a science-based medicine perspective, that it is even plausible. If the discovery is a drug that relaxes blood vessels, or a type of exercise, we have good reason to believe it might work and can go on to figuring out if it does work. If the intervention is wearing plaid every day, we have little reason to think this would be effective, and it probably isn’t worth the time and cost of looking into it.

The well-respected journal Cancer has just wasted space in the study of wearing plaid. Well, not really; it’s worse than that. The article is called, “Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A Randomized Controlled Trial.” There is nothing that isn’t wrong with this study, and if it weren’t published in a major journal, it might even be light comedy.

Tragedy wins the day, however, because cancer is a big deal, and I don’t like it when people mess around with cancer.(more…)

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A number of years ago I was walking along Lake Michigan with a friend (a fellow medical resident) when she turned to me and said, “are you wheezing? Do you have asthma?” I had always been physically active and assumed my breathlessness while walking down the trail was due to the thirty extra pounds of pizza and doughnuts I’d acquired during residency. But she was right: I was wheezing and breathless and it didn’t feel good at all. I made an appointment with one of the hospital’s lung docs who took a good history, did a physical, and ran some pulmonary function tests. And I did have asthma. And it felt much, much better when I used proper medication, a feeling confirmed by my improving lung function tests. (Not too surprisingly, the asthma got even better when I lost 40 lbs and started treatment for my acid reflux.)

I still get mild asthma symptoms from time to time, especially when I get sick, but for many others, the picture isn’t so pretty. Asthma kills at least a quarter of a million people every year around the world. If you’ve ever worked in an ER and seen a kid with a bad asthma attack, you’ve earned a healthy respect for the disease. If you’ve ever watched your own kid gasping for breath, begging you to make it better, you’ve learned to fear it.

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There are a few “laws” of the blogosphere, one of them being that a response to a post that comes more than a few weeks later is generally useless or crazy. But once in a while, someone takes the time to look at an old post and formulate a thoughtful response.

I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written. I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease. I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education. I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.

In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.

I await your response.

Sincerely,

[Name redacted]

What is instructive here is the usual thoughtful but incorrect “reasoning” used by someone with just enough knowledge to think he understands the topic at hand well enough to rebut. The rebuttal, however, makes use of the usual fallacies that are the fallback position for the ignorant and the mendacious (and I must point out that I think our Dear Correspondent is the former).

Since I wrote the piece, not Dr. Gorski, I take full responsibility for its content and defend my writing personally. A bit of a fisking is in order to help us all better understand how to think about these questions properly.

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Dr. Mehmet Oz is one of America’s most influential doctors. Just ask him. He has a TV show and everything. And in the past, much of his advice had been practical and mundane, the same advice you might hear from your own (perhaps less charismatic) physician. But lately, he’s been giving out frankly bizarre medical opinions. Not all of Oz’s recommendations are over-the-top strange, but even some of his less-bizarre stuff is hyperbolic to the point of being—in my opinion—deceptive. Let’s explore one example close to my heart, diabetes. As an internist, one of my most important tasks is the prevention and treatment of diabetes. I know something about it. As a heart surgeon, Dr. Oz deals with one of the most serious complications of diabetes, coronary heard disease, so he must know a bit about it as well.

So I was a bit surprised to learn from his website that I’ve been going after diabetes the wrong way. Unknown to me is the “prevention powerhouse” of coffee and vinegar. He recommends heavy consumption of these miracle foods to prevent diabetes and to help the liver and cholesterol, whatever that means. Reading this, two questions come to mind (a few more, really, but two that we will focus on): is this plausible, and is this true?(more…)

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One of the most significant medical advancements of the last few decades has been the use of cholesterol-lowering medications called statins. These drugs, when used properly, have been shown over and over to lower the risk of heart attacks, strokes, and death. But like all drugs, they have many effects, both those we like (preventing heart attacks) and those we don’t (in this case, rare liver and muscle problems); the latter we call “side-effects”. Studies done on drugs before they hit the market can identify common side-effects, but it’s not until many more people are exposed for a long period of time that rare side-effects show up.

A recent Scientific American article wondered if one of these rare side-effects could be memory problems. At first glance, the idea seems pretty improbable, but the SI article takes some sketchy anecdotes and runs with the idea, managing to cobble together an interesting hypothesis: (more…)

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Sixty years ago, the world was full of miracles. Western Europe was recovering from the devastation of World War II, an agricultural revolution promised to banish the fear of starvation in large parts of the world, and the mythical Mad Men era gave Americans a taste of technology-dependent peace and prosperity unlike any in the past. Despite the technological progress that would soon send animals into space and return them relatively unharmed, Americans, and westerners in general, were still dying of heart disease at a frightening rate. If you, as a middle aged American, experienced chest pain and were lucky enough to make it to a hospital (about 20% of all sufferers would die immediately), you would probably be given nitroglycerin and morphine to control you pain, put on bed rest, and could expect to live a few more years, with limited physical activity.

Heart disease continues to be a top killer of Americans, but there has been a dramatic decline in heart disease mortality in the last 60 years, with age-specific mortality rates dropping 60%. Fewer people are developing heart disease, and those that have it are living longer. It is estimated that in 2000 alone, there were 341,745 fewer heart disease deaths than would have been expected if rates had remained unchanged. This decline has not been driven by a renaissance of alternative medicine. It has been driven by science.

The trend has been going on for many decades, and has been accelerating, although current trends in diabetes and obesity put us at risk for more overall cases of heart disease in the future. So what are we doing right? How have we managed to cut the death rate from heart disease so dramatically?(more…)